QCDR data entry - CPRA Hospital - Copy 2 Provider Name:*Provider Name who personally performed case. First Last Facility:Middle Park Medical CenterFacility Type:*Type of anesthesia that was administered during case.HospitalDate of Service:*Date of service case occurred. Month Day Year Patient Name:*Patient name as it appears on patient sticker. First Last Date of Birth:*Patients date of birth. Month Day Year GenderFemaleMaleAnesthesia Type:GeneralMAC / IV SedationMAC / Block comboSpinalAxillary BlockASA Physical StatusASA 1ASA 2ASA 3ASA 4Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin*21 Yes No N/A Documentation of Current Medications in the Medical Record*130 Yes No N/A Sleep Apnea: Assessment of Sleep Symptoms*276 Yes No N/A Patient - Centered Surgical Risk Assessment and Communication358 Yes No N/A Anesthesiology Smoking Abstinence*404 Yes No N/A Perioperative Temperature Management*424 Yes No N/A Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)*426 Yes No N/A Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy*430 Yes No N/A Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery*44 Yes No N/A Medication Reconciliation Post-Discharge*46 Yes No N/A Care Plan*47 Yes No N/A Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections*76 Yes No N/A Pain Assessment and Follow-Up*131 Yes No N/A Coronary Artery Bypass Graft (CABG): Stroke*166 Yes No N/A Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet*352 Yes No N/A Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)*427 Yes No N/A Case delayed reason Anesthesia delay Surgeon tardy Patient tardy Medical reason OR delay Exceeded allotted time in prior case Facility staff delay Lab delay Equipment delay Case cancelled reason Anesthesia cancelled - medical necessity Surgeon cancelled Facility cancelled Patient no show Difficult Airway Yes No Unexpected transfer to Hospital Precautionary - patient alert Emergency - patient unresponsive Adverse Outcome Yes No